How to Build an Effective Palliative
Care Program
Carla Braveman, Elliot Health System
Sharyl Kooyer, Sutter Care at Home
Bill Musick, Corridor
NAHC Financial Management Conference – June 2015 Session 102 2 NAHC HHFMA WORKGROUPNAHC HHFMA Palliative Care White Paper
2015 Contributors: Walter Borginis, Carla Braveman, Sharyl Kooyer, Cheryl Leslie, Pam Meliso, Bill Musick (Editor in Chief), Shawn Ricketts, Lisa Roberts, Joshua SullivanINTRODUCTION
Overview 3Palliative Care
Who-What-When-Where-How-Why
Made Easy
Objectives
4Flow
1. Context: Models and Issues
2. Specific Case Studies
•
Elliot Palliative Care Services
–
Elliot Health System
•
Advanced Illness Management
(AIM) Program – Sutter Care at
Home
3. Q&A
5Caveats
•
“If you’ve seen one palliative care program, you’ve seen
one palliative care program.”
•
Regulations vary by state and by payer and are
continually evolving – please don’t take our comments as
legal advice
•
Beware of relying too much upon someone else’s
experience
6Questions in the room…
7
CONTEXT
Palliative Care Models
What?
9 Disease Progression Hospice Care Palliative Care Terminal Phase of Illness Death Bereavement Support Diagnosis of Life-threatening or Debilitating Illness or Injury Manageable, early, stable conditions Serious, progressive conditions that limit daily activitiesAdvanced Illness Management
What is Palliative Care?
Center to Advance Palliative Care (CAPC)
Specialized care for people with serious illnesses •Focused on relief from the symptoms, pain, and stress of a serious illness •goal is to improve quality of life for both the patient and the family •provided by a team of doctors, nurses and other specialists who provide an extra layer of support at any age and at any stage in a serious illness and can be provided along with curative treatment •support patient and family, not only by controlling symptoms, but also by helping to understand treatment options and goals 10What is Palliative Care?
Center to Advance Palliative Care (CAPC) •The palliative care team provides: • Expert management of pain and other symptoms • Emotional and spiritual support • Close communication • Help navigating the healthcare system • Guidance with difficult and complex treatment choices 11Variations
•
Setting
•
Task‐specific
(Advanced Directives vs P&SM)•
Disease‐specific
(Cancer vs CHF)•
Symptom‐specific
(Pain) 12 Acute Skilled Nursing Hospice Home Health Primary Care Specialty/ General ClinicsGET PAID
Palliative Care
13
HOW TO MAKE MONEY BREAK EVEN
Payment
Billable Entitlement Programs
•
Medicare Part B
•
Physician/NP
•
LCSW
(using mental health billing codes only)•
Medicare Part A ‐ Home Health
•
Concurrent Hospice Care
•
Medicaid Pediatric Concurrent Care
•
Commercial Insurers
•
CMS Demonstration Project??
14 Revenue CostPayment
(continued)
Entrepreneurial
•
Contracts
•
Commercial Insurer
•
Hospital/Health System
•
Innovation Award/ACO/Bundled Payment
•
Philanthropic
•
Research
•
Foundations
•
Private Pay Fee for Service (Concierge)
15Cost Avoidance in Lieu of
Payment
16System-wide
Cost
Savings/
Outcomes
Net
Investment
in Palliative
Care
WHO and WHY
Palliative Care 17*
*
Why?
•
Service Goals
•
Unmet need
•
Move “upstream”
•
Discharge option
•
Financial Goals
•
Loss is OK (at least to start)
•
Break even
•
Financial contribution
18Who?
•
All with need
•
Top potential for savings
•
Segmented population
19Highest
Cost
Disease
Management
Pre/Post‐Hospice
Examples of Delivery Models
Palliative Care 20Examples: Advance Care Planning
Gundersen Health System’s Respecting Choices Program
21Example: UPHS CLAIM Project
University of Pennsylvania Health System CLAIM Project
(Comprehensive Longitudinal Advanced Illness
Management)
•
Home Health‐based program with supplemental
disciplines
•
Cancer
•
Goal: reduce unnecessary end of life care costs and
decreased quality of life
•
Seed funding: Health Care Innovation Awards
•
Long‐term: Cost avoidance, outcome improvements
22Example: Lehigh Valley Health Network
•
Optimizing Advanced Complex Illness Support (OACIS)
•
Three‐pronged service
• OACIS Home‐Based Consult Service • OACIS/Palliative Medicine Inpatient Consult Service • Palliative Care Outpatient Clinic (PCOC) – Cancer Center•
Medical Director, APNs, RN Case Manager
•
Cost avoidance/improved outcomes
23Examples: Entrepreneurial Services
•
Contractual arrangements by hospices/home health
agencies to provide a combination of:
• Billable physician/NP services with • Hospital payment for social work/chaplain and/or physician/NP administrative time•
Palliative care providers at risk for achieving savings
through identification and care of high‐cost chronic care
patients (insurer or health system, ACO)
24Comments/questions…
25ELLIOT PALLIATIVE
CARE SERVICES
Manchester, NH
26Southern
New Hampshire
• 1.3 Million people live in NH • 400,000 in primary service area 27 28Elliot Health System
•
Elliot Hospital – 296 beds
•
Urgent Care – 2
•
Ambulatory Care Centers – 3
•
Elliot Primary Care Network – 97
•
Elliot Specialty Care Network – 245
•
Home Care, Hospice, Personal Services
•
NH Hospital for Children
•
Regional Trauma Center
29History
•
5‐10 years of Palliative Care Steering
Committee
•
Launched hospital based APRN model
•
200‐ 250 encounters/ year
•
Chair of Hospitalists provided medical
oversight
•
Stagnant without physician leadership
30Palliative Care at Home
•
0.5FTE APRN
•
Never set up the billing component
•
Worked out of hospice department
•
Retrospective review = non billable visits
•
Closed program in 2012
•
Hospice information visits vs. PC consults
31Reinvented the Model‐ 2012
•
Hired Physician Boarded in IM and HPM
•
Inpatient care
•
Pain and symptom management
•
Clarification of treatment goals
•
Provider education‐ not just brink of
death
•
Value to providers‐ starting with
hospitalists
•
Medical Staff Bylaws
32Current Activities Promoting PC
•
Rounds on ICU weekly
•
Ethics Committee Membership
•
State Palliative Care Committee
•
Presentations at AAHPM
•
Elliot Grand Rounds and Schwartz Rounds
presentations
•
Medical Staff Meeting presentations
•
Constant evolution and communication
•
Embedded in hospitalist area in hospital
332015 Sites of Care
Inpatient Hospital
Skilled Nursing Homes – 6
Hematology Oncology practice
Radiation Oncology practice
34APRN
1.0 FTE hospital
0.4 FTE SNF
Board Certified MD’s
Medical Director – 0.8 FTE
0.2 FTE for hospice Medical Director
3 Shared Physician‐ 0.45 FTE’s
Licensed Clinical Social Worker (LCSW) ‐
DSM diagnoses
2015 Staffing
35Productivity
•
Productivity metrics – hard to find
•
Several articles suggested
•
250 consults and 1000 revisits / full time
provider
•
Our Experience
•
APRN 10% less
•
MD 10% more
36Statistics FY 15 projected
37
Site
Consults
Revisits
Hospital
746
2,274
Nursing Home
264
430
Outpatients
30
15
Total = 3,759
1,040
2,719
38 Top 25 Diagnoses wRVUs 786.09 ‐ Other dyspnea and respiratory abnormal 788 307.9 ‐ Other and unspecified special symptom 314 780.96 ‐ Generalized pain 253 294.20 ‐ Dementia, unspecified, without behavioral 252 518.81 ‐ Acute respiratory failure 189 338.3 ‐ Neoplasm related pain (acute) (chronic) 210 496 ‐ Chronic airway obstruction 181 331.0 ‐ Alzheimer's disease 180 294.21 ‐ Dementia, unspecified, with behavioral 95 780.97 ‐ Altered mental status 142 428.0 ‐ Congestive heart failure, unspecified 138 300.00 ‐ Anxiety state, unspecified 123 789.00 ‐ Abdominal pain, unspecified site 116 780.09 ‐ Other alteration of consciousness 104 724.5 ‐ Backache, unspecified 86 486 ‐ Pneumonia, organism unspecified 90 585.6 ‐ End stage renal disease 68 491.21 ‐ Obstructive chronic bronchitis with 66 434.91 ‐ Unspecified cerebral artery occlusion 7239 Top 25 Diagnoses wRVUs 162.9 ‐ Malignant neoplasm of bronchus and 57 518.84 ‐ Acute and chronic respiratory failure 59 780.79 ‐ Other malaise and fatigue 52 572.8 ‐ Other sequelae of chronic liver dis 56 311 ‐ Depressive disorder, not elsewhere 35 584.9 ‐ Acute kidney failure, unspecified 51 Total Top 25 3,780
Financial
#1. Physician coders do not
understand palliative care or
billing by time
40Financial
•
Initially, 60% of claims were down coded
by the internal hospital coding team
•
2012 Consultant‐ specific to PC
•
No change
•
Consultant returned and approached it
coder by coder using down coded claims
•
<5% of code changes today
41Budget 2015
Revenue Gross Revenue $638,756 CA/ Charity/ Bad Debt $279,506 Net Revenue $359,250 Expenses Salaries $523,951 other $22,051 Total Expenses $523,921 Net ($164,657) 42Financial
•
Rationale for system support
₋ Cost avoidance model for inpatient
₋ ICU discharges to prevent diversions in the ED₋ Readmission reduction model for NH
₋ Hospice Referrals
43 44 Top 20 Procedures (by Occurrences) ‐ FYTD, By Charge Posting Period OCCURRENCE CHARGES wRVUs 99232 ‐ SUBSEQUENT HOSP CARE,MOD 864 $ 126,861 1,201 99231 ‐ SUBSEQUENT HOSPITAL CARE, 627 $ 50,787 477 99223 ‐ INITIAL HOSPITAL CARE,HIG 481 $ 195,767 1,857 99233 ‐ SUBSEQUENT HOSPITAL CARE, 246 $ 51,906 492 99308 ‐ SUB NURS FACIL CARE‐LOW C 196 $ 26,852 227 99306 ‐ INIT NURS FACIL CARE‐HIGH 129 $ 42,570 395 99309 ‐ SUB NURS FACIL CARE‐MOD C 125 $ 22,750 194 99305 ‐ INIT NURS FACIL CARE‐MOD 63 $ 16,317 148 99310 ‐ SUB NURS FACIL CARE‐HIGH 44 $ 11,792 10345
OCCURRENCE CHARGES wRVUs 99222 ‐ INITIAL HOSPITAL CARE 24 $ 6,624 63 99205 ‐ NEW PT,COMPREHEN,HIGH(992 11 $ 4,565 35 99356 ‐ PROLONGED SERVICE, INPATIENT 11 $ 2,024 19 99215 ‐ EST PT,COMPREHEN,HIGH(992 9 $ 2,628 19 99254 ‐ INPT CONSULT, COMPREH, MO 7 $ 2,016 23 99214 ‐ EST PT,DETAIL,MOD‐HIGH(99 6 $ 1,302 9 99357 ‐ PROLONGED SERVICE, INPATI 6 $ 1,110 10 99304 ‐ INIT NURS FACIL CARE‐LOW 5 $ 920 8 99245 ‐ OFFICE CONSULT, COMPREH, 4 $ 1,560 15 99345 ‐ HOME VISIT, NEW PT, HIGH 4 $ 1,772 16
Comments/questions…
46Sutter Health / Sutter Care at Home
Advanced Illness Management (AIM
®)
A Model for Palliative Care and Complex Care
Management
47Health Care Innovations
Awards –
Sutter Care at Home
Advanced Illness Management
“The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.”THE AIM JOURNEY: 2008 ‐
PRESENT
Identified the
gap/burden in care Research and design Implementation planning
Conduct pilot Evaluated pilot; decided on system wide implementation Secure funding Launch readiness planning Site implementation Infrastructure development Continuous program development, improvement, maturing Program evaluation‐ system & payer AIM Program Model : Better Health Better Care Lower Cost
•Imperative for AIM
•Model Design
Characteristics
•Person Centered
Care
•System Integration
•Impact on Care
Outcomes
"The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."
49
The ‘AIM’ Patient Experience
50
Source: Data of Sutter Experience –”The Care of Patients with
Severe Chronic Illness”. Dartmouth Atlas, 2006
Additional Statistics
• Medicare will spend 28% of all their payments on a patient in the last year of life
• Medicare will spend ~$214M per year for 5,000 patients in the last year of life
• Patients have a 25% chance of receiving hospice care where they will spend 8 days on service before dying
• Patients in the last year of their lives represent 5% of the population that spends the highest amount of Medicare dollars and take the most time and resources from providers
HOSPITALS • Emergency Dept. • Hospitalists • Inpatient palliative care • Case managers • Discharge planners MEDICAL OFFICES • Physicians • Office staff HOME-BASED SERVICES • Home health • Hospice • Telesupport
New AIM staff & services
911
• AIM Care Liaisons• Care managers • Telesupport CRITICAL EVENTS • Acute exacerbation • Pain crisis • Family anxiety CRITICAL EVENTS • Acute exacerbation • Pain crisis • Family anxiety
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
51
SYSTEM
FRAGMENTATION
SYSTEM
INTEGRATION
• Transitions Team Model Principles • Personal Goals • Person &Physician Relationship Central • Dual Therapeutic Approach Curative + Palliative • Evidenced Based Clinical Care and Care Management • Simplify and Drive Communication Target Population • > 2 Chronic Illnesses; >1 Illness Advancing • Poly‐pharmacy • Clinical, Functional, and/or Nutritional Decline • High Symptom Burden leading to repeat utilization • MD ‘Surprise Question’ 12 Months Pillars of Care • Advanced Care Plans • Self Management Plan of Red Flag Symptoms • Medication Management • Ongoing Follow Up Visits • Engagement & Self Management Support • Resting on Curative + Palliative Care Foundation Drivers of Outcome • Aware and Skilled in Health Literacy & Patient Engagement • Continue During Periods of Illness and ‘Wellness’, across all settings • Frequent & Predictable MD Communication • Teams Without Borders 52AIM
®MODEL DESIGN CHARACTERISTICS
• Teach Back • Chunk and Check • Motivational Interviewing • Evidence-based Care Management • Evidence-based Palliative Care • Bubble Diagrams • Stop Light Forms • SMART Goals
• Medication Management • POLST
• Mock Runs
• Personal Health Record
Clinician Patient/ Family
PERSON CENTERED CARE
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
53
Closer Look at Care Integration
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
STAFFING MODEL
AIM Team Members AIM Home Health (HH RNs, MSWs, plus other disciplines) AIM Transitions (former Hospice RNS and MSWs) AIM Hospital Based (AIM Care Liaison, RN, former Hospice) AIM Telesupport/ Office Based Case Management (RN – mixed experience)AIM
Team
Case Loads • AIM Home Health:13‐17 pts • AIM Transitions: 15‐20pts • AIM Telesupport: 60‐80pts • Medical Director: .2‐.3 FTE • AIM Administrator (also Hospice Administrator) • Leadership Team=HH, Hospice, AIMThe contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
55
AIM: TOTAL COST OF CARE
Total
Cost of
Care
Hospital Physician AIM Transitions AIM Telesupport/ Office Based Case Management Home Health (AIM) 56Examples of AIM Measures
57
• % Transferred to Hospice • % Died in Hospital
• Hospital Days in Last 6 months of life
• Ed Use in Last 30 Days of Life • ICU Use in Last 30 Days of Life • LOS of Hospice Stay
• Inpatient and ED visit Rates per 100 patients
• 30, 90 and 180 Day Pre/Post Enrollment Utilization
• Hospital • ED • ICU
• ALOS in Hospice • 90 Day Payer Impact, Hospital
Cost Impact, Total Cost of Care • Independent Research and
Evaluation
Care at the End of Life Outcomes, Resources and Costs
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
IMPACT ON CARE
• Now serving 15 counties; enrolled more than6,500 persons with advanced illness; 335 staff members trained
• Current census is 2100+; 85,000 patient contacts last 12 months
• CMS awarded Sutter with a $13 million Innovation Challenge grant to fund the ongoing implementation and evaluation of the AIM program; Sutter provided $21.4 M • Ongoing high patient and provider
satisfaction. Improving Health Improving Care Lowering Cost 58
Interim Results: 90 Day Pre/Post Cost Analysis
12 Months Rolling Q2 2013‐ Q1 2014 9 Out of 10 Sites Reporting
(Results not yet confirmed independently by CMS Evaluators)
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. ‐$18,000,000 ‐$16,000,000 ‐$14,000,000 ‐$12,000,000 ‐$10,000,000 ‐$8,000,000 ‐$6,000,000 ‐$4,000,000 ‐$2,000,000 $0 ‐$15,417,246 ‐$16,400,188 ‐$12,799,460 Cost of Care Impact (N=1,544) Change in Net Charges Billed to Payers Change in Hospital Costs Change in Total Sutter Costs ‐$12,000 ‐$10,000 ‐$8,000 ‐$6,000 ‐$4,000 ‐$2,000 $0 ‐$9,985 ‐$10,622 ‐$8,290 Cost of Care Impact Per Enrollee (N=1,544) Change in Net Charges Billed to Payers Change in Hospital Costs Change in Total Sutter Costs 59
CHALLENGES
Time required to adopt and hardwire new clinical and care management skills Regulatory & legal environment not aligned with health care reform innovation Immediate demand for clinical, operation, and financial integration outpaced IS infrastructure Resources and skills to perform specialty analytics in timely, consistent and reliable manner Expanding Access to AIM Services and Evaluating the Model of Care 60OPPORTUNITIES
Investment in infrastructure for broader complex care management Participate in design or evaluation of model of care for persons with advanced illness Develop new payment model to serve this complex growing population of patients 61The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
Fee For Service
Value Based Population Reimbursement
living in two worlds at the
same time
is challenging
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the
The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
63
Health Care Innovations
Awards
•“The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.” 64Resources
•
What is Palliative Care?, Center to Advance Palliative
Care, 2012
http://www.getpalliativecare.org/whatis/•
Palliative Care Services: Solutions for Better Patient Care
and Today’s Health Care Delivery Challenges, American
Hospital Association, November 2012,
http://www.hpoe.org/Reports‐ HPOE/palliative_care_services_solutions_better_patient_care.pdf•
Hospice and Palliative Medicine: What Are the Next
Steps for a Match (National Resident Matching Program)
(2012) Signer
http://apps.aahpm.org/Default.aspx?TabID=251&ProductId=594 65Resources
•
University of Pennsylvania School of Medicine. "Care At
The End Of Life: Room For Improvement, Ideas For
Change." Medical News Today. MediLexicon, Intl., 23
May. 2013. Web. 12 Aug. 2013.
http://www.medicalnewstoday.com/releases/260840.php•
Palliative Care and Hospice Care Across the Continuum,
Center to Advance Palliative Care,
http://www.capc.org/palliative‐care‐across‐the‐continuum/•
Improving Care for People with Serious Illness through
Innovative Payer‐Provider Partnerships, Center to
Advance Palliative Care,
http://www.capc.org/payertoolkit/ 66Contact Information
Carla Braveman
– VP Home & Community Services, Elliot Health System CBraveman@Elliot‐HS.org(603) 622‐3781
Sharyl Kooyer
– AIM Program Director, Sutter Care at Home [email protected] (916) 797‐7856Bill Musick
‐ Senior Associate, Corridor [email protected] (888) 942‐0405 (toll‐free) 67Comments/questions…
68Compare & Contrast
Targeting and Triggers*
Interdisciplinary Team Composition*
24/7 Clinical Response *
Integrated Medical and Social Supports*
Concurrent Care*
Setting‐Specific or Agnostic?
69 * CAPC Essential Structural Characteristics of High-Value Palliative CarePLANNING AND DEVELOPMENT
CONSIDERATIONS
Palliative Care
Issues in Financial Viability
•
Incomplete payment mechanisms
•
Optimal utilization of high‐cost providers
•
Over‐extending services
• Services provided • Patients served 71Tips from the field
Payment
• Do not expect PC to generate a profit • Do bill Part A and/or B and do it well (attention to accuracy and coding) • Don’t give away PC ‐ get a fair payment from hospitals • Require hospital partners to measure the impact of PC 72Tips
•
Focus on local needs
•
Look for creative leveraging of
• Other community resources • All possible funding sources•
When possible, shoot bullets first, then cannon balls
73Tips
(continued)
•
Think outside of legacy models
•
Hospital executives rank trust and compatible culture
of partners higher than logistics/systems
•
Value of practice management
74Messaging Tips
Especially for hospice providers…
•
No one knows what you will and will not do as a
palliative care provider – tell them
• Providers and consumers do not understand palliative care or hospice – saying one is not the other is not a clarification • Avoid describing palliative care as ‘hospice light’ – it is exactlyas it sounds – less ‐ and not as good as should be expected
NAHC HHFMA Palliative Care White Paper
6/24/2015
Contributors: Walter Borginis, Carla Braveman, Sharyl Kooyer, Cheryl Leslie,
Pam Meliso, Bill Musick (Editor in Chief), Shawn Ricketts, Lynn Roberts, Joshua
Sullivan
With review by: NAHC staff and members of the
Hospice Association of America Advisory Board
The U.S. health care system is in a state of rapid change. The impact of these shifting programs and incentives—and both their beneficial and unintended negative consequences—on Americans nearing the end of life should not be overlooked. Appropriate measurement and accountability structures are needed to ensure that people nearing the end of life will benefit under changing program policies. In assessing how the U.S. health care system affects Americans near the end of life, the committee focused on evidence that the current system is characterized by fragmentation and inefficiency, inadequate treatment of pain and other distressing symptoms, frequent transitions among care settings, and enormous and growing care responsibilities for families. Institute of Medicine (IOM) Report, Dying in America, 2014, page 5‐3
Contents
I. Palliative Care – An Overview ... 4 A. Introduction ... 4 B. Caveats ... 4 C. Context ... 5 D. Payment ... 6 E. Palliative Care Program Goals and Target Populations... 6 F. The Variety of Palliative Care Programs ... 7 II. Starting a Palliative Care Program ... 8 A. Palliative Care Program Goals and Target Populations ... 8 B. Measurement of Patient Potential ... 8 C. Identification of Referral Sources ... 9 D. Identification of Key Value Statement Items for the Program ... 10 E. Personnel, Structure and Other Resources That Support a Robust Palliative Care Program ... 11 III. Clinical Aspects of Palliative Care ... 13 A. Case Example: Physician‐Based Palliative Care Services Model ... 13 B. Case Example: Sutter Health’s Advanced Illness Management ... 14 Program Overview ... 15 AIM Patients ... 15 AIM Care ... 16 Core Staffing and Tiers of Service ... 16 AIM Patient Flow ... 17 Competencies ... 17 Relationship to Home Health and Hospice ... 17D. Medicaid Coverage for PC Services ... 23 E. Private Insurance Coverage for PC Services ... 23 F. Veterans Health Administration (VA) Coverage for PC Services ... 24 G. Alternative Methods of Funding Palliative Care ... 24 H. Proposed Legislation in Support of Palliative Care Planning ... 24 I. Summary ‐ Reimbursement for PC Services ... 25 V. The Value Proposition for Palliative Care ... 26 A. Marketing Palliative Care Services ... 26 B. Making the Case for PC – Metrics ... 28 VI. Next Steps ... 30 A. Sharing Best Practices ... 30 B. Policy Advocacy ... 30
A. Introduction
Palliative Care (PC) and its “cousin,” Advanced Illness Management, answer a significant need of today’s health care system; however, the absence of a regulated model of care and reimbursement create both opportunities and challenges for home health and hospice organizations that provide this service. This paper is intended to share concepts and experience for providers who desire to explore and develop their own PC program. PC programs have developed in response to needs which vary from situation to situation, and, as a result, it is difficult to provide guidance that is standardized or applicable to all situations. In this paper, the contributors share more generalized concepts, as well as details about some of the variations that exist across the United States. This paper addresses PC from the perspective of a home health or hospice provider.B. Caveats
As already noted, PC programs have developed differently in each market to meet specific needs. As a result, the general consensus is “if you’ve seen one PC program, you’ve seen one PC program.” Each program should be developed to meet unique goals and criteria, drawing upon the experience of others, but Throughout the trajectory of illness, palliative medicine providers optimize disease management through comprehensive assessment, symptom management, and supportive care to patients and caregivers. This model of care enhances quality of life from the curative/restorative care stage through caregiver bereavement. Barriers and silos of care exist that impede advanced disease symptom management. Physician reimbursement and billing issues negatively impact the ability to provide palliative care services for treatment of advanced, end stage chronic diseases. For those nearing the end of life, better quality of care through a range of new delivery models has repeatedly been shown to reduce the need for frequent 911 calls, emergency department visits, and unnecessary urgent hospitalizations. Evidence suggests that palliative care, hospice, and various care models that integrate health care and supporting services may provide high‐ quality end‐of‐life care that can reduce the use of expensive hospital and institution‐based services, and have the potential to help stabilize and even reduce health care costs for people near the end of life. The resulting savings could be used to fund highly targeted and carefully tailored supporting services for both children and adults (Komisar and Feder, 2011; Unroe and Meier, 2013), improving patient care while protecting and supporting families. Services must be tailored to the evolving needs of seriously ill individuals and families so as to provide a positive alternative to costly acute care and to help these patients remain safely at home, if that is their preference.The Center to Advance Palliative Care (CAPC) defines PC as “specialized care for people with serious illnesses,” with the following characteristics: • Focuses on relief from the symptoms, pain, and stress of a serious illness • Aims to improve quality of life for both the patient and the family • Provides an extra layer of support at any age and at any stage in a serious illness, and can be provided along with curative treatment • Supports patient and family, not only by controlling symptoms, but also by helping to understand treatment options and goals CAPC further tasks the PC team with: • Expert management of pain and other symptoms Disease Progression Hospice Care Palliative Care Terminal Phase of Illness Death Bereavement Support Diagnosis of Life-Threatening or Debilitating Illness or Injury Manageable, early, stable conditions
Serious, progressive conditions that limit daily activities
PC can focus on one or some combination of the tasks above. It can also focus on a specific setting, such as a clinic or physician office, nursing facility or hospital, or be home‐based. It can also be focused on specific diseases or specific symptoms (such as pain). There are untold variations that could express the combination of settings, disease focus, task, symptom(s) and delivery method available.
D. Payment
One of the key challenges for PC programs is financial sustainability. Historically, most hospice and home health agencies have looked to established government payment mechanisms to fund PC services. These sources are Medicare Part B payment for physician, nurse practitioner (NP), psychologist and limited situations of Licensed Clinical Social Worker (LCSW) services, home health reimbursement or concurrent hospice care reimbursement available through Medicaid for pediatric patients or via demonstration projects. These sources rarely cover the full cost of providing PC services. Therefore, providers are increasingly looking to other sources of funding to supplement traditional payment streams. These additional sources of funding include: grants, commercial insurance contracts, arrangements with hospitals or health systems, arrangements with ACO’s or other bundled payment payers, or private pay (concierge) models. All of these sources usually entail some restrictions, such as limited duration, limited target populations, application for limited funds, and/or other aspects that require initiative and negotiation. These sources of funding are usually premised on the ability of PC to avoid cost that would otherwise be incurred under other payment models, especially long lengths of stay in hospitals and ICU level of care days. This ability for PC to result in system‐wide cost savings and/or improved outcomes is helping to fuel the growth of PC programs, but, nonetheless, makes it difficult to justify PC on its own as a stand‐alone service line.E. Palliative Care Program Goals and Target Populations
The newer sources of funding mentioned above are driving many PC providers to examine the goals of their programs more closely. Some target their programs on a specific target population that meets the needs of a particular funding source; others target patients that are either immediately “upstream” or “downstream” from their core hospice and/or home health service, while others focus on meeting unmet needs, regardless of available funding or cross‐program benefit. A related decision that PCF. The Variety of Palliative Care Programs
As a result of the various factors outlined above, PC programs have developed to address different goals, settings and diseases. These variations bring with them different staffing models as well. One key factor in sustainable delivery of PC is the non‐productive time of highly paid staff. Many programs focus on settings where physicians, NPs and other staff can be as productive as possible: hospitals, SNFs and clinics. In‐person home‐based PC, with its related travel time, continues to be a challenge with respect to productive use of staff. Later sections of this paper include more detailed examples of specific programs, but here are just a few examples that typify the range of approaches that different providers bring to PC (information provided based upon publicly available information that may not be entirely up to date): Gundersen Health System’s Respecting Choices Program: A staged approach to advance care planning which addresses that single component of PC. University of Pennsylvania CLAIM (Comprehensive Longitudinal Advanced Illness Management): A home‐health based program focused on cost avoidance and improved outcomes for cancer care by providing supplemental disciplines; funded by a Health Care Innovation Award from the Centers for Medicare and Medicaid Services (CMS). Lehigh Valley Health Network’s Optimizing Advanced Complex Illness Support (OACIS): A RN case‐ managed three‐pronged service consisting of home‐based NP consults, palliative medicine inpatient consult service, and a PC outpatient clinic associated with a cancer center intended to avoid cost and improve outcomes. Hospice of Michigan’s At Home Choices: ™ A RN case‐managed set of services coupled with advanced informatics to target patients whose costs have the greatest probability of being modified by PC interventions, and is funded by contractual agreements with insurers or health systems. See other sections of this report for more detailed discussion of other aspects of PC program development and operations.Starting a
Palliative
Care Program
This section serves as an overview for many of the aspects necessary for the start‐up of a successful PC program. More details are provided in the other sections of this document.A. Palliative Care Program Goals and Target Populations
As noted in Section E of the previous chapter, PC program development needs to begin with a clear understanding of programmatic and financial goals that are shared across the organization and tested within your local community. Without this clarity, it is difficult, if not impossible, to build a successful PC service. It is worthwhile to make sure that you have a firm foundation in terms of expectations before beginning any of the other elements below. Discussions and considerations regarding program goals may include an iterative process of developing goals and testing them in terms of organization and community feedback.B. Measurement of Patient Potential
Criteria for Potential Referral Sources and Site of Service—In developing a PC program, it is important to define the criteria for potential referral sources for outpatient, facility, and home based PC programs, as well as the potential for inpatient PC services. This definition will help identify the best potential referral sources in your community and the possible sites of inpatient PC. Medicare market data is available for purchase. It will allow you to compare potential hospital‐based consultation needs, as well as referral sources for community based care, by giving you data relative to hospital discharges and diagnoses. This will allow you to quantify the potential referral base from each source and to rank potential sources against each other in order to prioritize which sources to target. Unfortunately, there is little to no data available regarding non‐Medicare payers. Identification of Types of Patients Most Likely to Need Palliative Care—As described in the prior section, you can use Medicare market data to identify the size of each referral source’s potential patient base. In order to do this, you need to obtain hospital or Skilled Nursing Facility (SNF) discharge data with diagnosis information. As part of this exercise, you should identify which diagnoses are most likely to need PC and hospice services. For example, cancer, congestive heart failure, and COPD diagnoses are frequently seen among PC, home health, and hospice patients. PC providers based in hospital inpatient consultation services have used five percent of hospital census, excluding maternity and any inpatient psychiatric patients, as an estimate of potential PC consults andUsing Market Data on Hospital Discharges—You can purchase the Medicare market data that reflects the actual discharge by diagnoses information for each hospital in your service area. This data will help you identify the best possible referral sources for potential PC patients that, by diagnosis, may eventually become hospice patients as well. Discussions with Existing Referral Sources—Once you have determined the site of services and armed with discharge information, the next step would be to meet with existing referral sources to identify if there is another PC provider serving their patients or if you may be able to serve those patients. Since the social work and chaplaincy costs are not covered by insurance payments, it is important to discuss the costs involved for the referral source to use your PC program. It is prohibited to give those services away for free since that would be viewed as a benefit offered to induce referrals. Analysis of Competing Programs—If your discussions uncover the presence of competing programs in your market or at your current referral sources, it is important to quantify why your program is better than the competing services and what additional benefits you offer as part of your service. In essence, you must construct a detailed value proposition in order to sell the use of these services to potential referral sources. The fact that you accept many insurances held by existing patients of that site, as well as the ability to provide careful coordination of care and seamless care transitions, are important factors. In addition, the ability to offer home health services as a bridge to patients that may not be ready to elect hospice is a benefit to the referral source in assisting with reducing their overall length of stay, as a well as a benefit to the patient by offering well‐coordinated care with the same clinical staff. Education of Medical Staff at Selected Site(s)—A key to a successful implementation is to convince the existing medical staff at the referral source site of the benefits of the PC program. Obviously, there is a benefit to the medical staff of having a very qualified and professional resource in place to handle the difficult conversations with patients and their families over the best course for a failing or seriously ill patient. In addition, many physicians need to understand the true scope of the PC program in order to receive referrals from them on an inpatient consultation level. Your PC physician must be able to sell the program to the medical staff on a department by department basis. They must be able to clearly define the benefit to the referring clinician. This is not a case of if you build it, they will come. Don’t forget to include the residents and hospitalists in your meetings. They have a lot of control over the flow of inpatient services and can make a real impact on your successful implementation. Medical Directors and Advance Practice Registered Nurses at the SNFs where you have a PC contract are also important people to educate. Specialty practices with potential for PC referrals include oncology,
progress toward a return home or transition to hospice within the facility in order to guarantee continuation of PC services. Try to have each team member meet each of the hospital’s discharge planning staff, and even nurse navigators. This personal touch will help identify the program and solidify referral opportunities.
D. Identification of Key Value Statement Items for the Program
Identifying and Defining Patients for the Program—It is important to clearly define the types of patients that you are seeking in order to clarify for the referral sources who are the appropriate patients for the PC program. When looking at Medicare PC programs embedded in a home health agency, it is important to clearly define the definition of homebound in order to make sure that appropriate patients are being referred for the home health bridge to hospice services. This is often a misunderstood area for hospital discharge planners. In addition, it is important to know which insurances you have under contract for physician consultations. It is a time consuming process to negotiate contracts for physician services and to credential each member of your medical staff in order to permit professional billing for the program. Most nursing facilities require credentialing, as medical staff and all hospitals require credentialing for physician services to occur. In addition, to bill Medicare, you must have a Part B number for the group physician practice. In your planning process, please allow sufficient time for contracting and credentialing or you will find that you will not be able to bill for your services. Lowering Hospital Length of Stay and Unplanned Readmissions—A key benefit to a referring hospital is the ability of the PC program to reduce length of stay for difficult patients who may not be willing to be discharged without a proper care alternative and to decrease unplanned hospital readmissions as symptoms are better managed at home. Facing terminal illness is a difficult process, and family members may be anxious about their ability to provide adequate care to their loved one. Patients living alone face the same, if not more anxiety, as they face the prospect of life outside of the hospital under their own care. A good PC program will provide a welcome alternative to these concerns, as well as an appropriate level of care outside the hospital. PC programs providing consultations within a hospital will also decrease the length of stay within the hospital, and particularly within the ICU or CCU areas, by clarification of treatment goals and symptom management. Increasing Patient Satisfaction—By reducing patient and family anxieties as described above, the referring hospital will find an increase in patient satisfaction. This is due to the ability of the PC program to provide quality care in the patient’s home. The program will help the patient and their family transition to home, as well as provide much needed information on the patient’s prognosis and what toE. Personnel, Structure and Other Resources That Support a Robust
Palliative Care Program
Need for the Right Physician and Nurse Practitioner—In order for the program to be really successful, careful thought must be given to select the right people to serve in the key roles of doctor and nurse practitioner. The people selected must have the appropriate background and experience in PC and hospice. For the doctor, board certification in hospice and PC is a necessity. In addition, you want people that will be able to actively and continuously educate providers and market the program. This requires excellent communication and diplomacy skills. Remember that marketing includes securing appropriate new sites for the program, as well as marketing the program internally throughout that site, in order to insure full utilization by the patients at that site. Both marketing efforts are necessary to insure success. Frequently, there will be other doctors on site that may not accept the program. They will need to be contacted directly by the program’s doctor, who must constantly discuss the merits of the program and how the program will relieve the doctor of the difficult conversations regarding a patient’s prognosis and how they want to best deal with death. It is amazing that complex medical school health systems somehow managed to avoid these discussions, even when it is in the patient’s best interest. They simply have been trained to treat patients until the end. Note: Some states have laws restricting the authority of the NP; check your state to see if the NP can practice independently, or can prescribe narcotics. Limitations in both of these areas will restrict the utilization of an NP. Need for the Right Social Worker and Chaplain‐‐‐If included in the staffing model, a program requires that the social worker and the chaplain have extensive experience in working with patients in both hospice and PC environments. It is important that they both be flexible in their approach to serving patients. Due to multiple conflicting demands, they may be called upon to function in each other’s role, especially as part of a family meeting. This will reinforce the team concept for the program, and it will be even more evident to families and patients that the team will do everything they can to make the patient comfortable. Careful selection based upon these traits is extremely necessary as these employees will really get involved in many patient and family details. They need great communication skills in order to facilitate difficult discussions. If visits are to be reimbursed, the social worker must be licensed in your state as a LCSW and appropriately credentialed in the hospital or nursing facility (if applicable), in addition to being included in your insurance contracting. Proper Placement of Home Health and Hospice Services within the Agency—The program will encounter many patients not yet ready to elect hospice. As a result, they may benefit from servicesstaff assigned to their care would remain constant. If traditional home health services were provided, the change in clinical staff may present a barrier to the hospice election. In addition, the need to transition a patient to hospice may not be appropriately recognized by the home health clinical staff. The goal is to have the patient receive the appropriate services they need, which many times necessitates the transfer to hospice. Other Resources—Other resources which should be considered essential elements in planning for a robust PC program include: • Data/analytics capacity • Ability to bill/code properly • Management of the mix of PC staff disciplines • Sales and marketing plan • Education/training plan • Compliance plan • Legal oversight
Palliative Care
This section provides details related to several models of PC or advanced illness management programs to include: target population, program description, staffing, and the relationship of the program to certified home health or hospice programs.
A. Case Example: Physician‐Based Palliative Care Services Model
Program Overview This is a medical model of PC in which physicians and NPs lead the team of interdisciplinary members. Based on the circumstance, often you will find social workers and chaplains that are shared between the PC service and other departments within hospitals or hospice programs. Occasionally, you will see a psychologist instead of the social worker, which allows for a higher rate of billing for services by the psychologist compared to the LCSW. Settings ‐ Site of care delivery is generally focused within an acute care facility, but may also be available in nursing homes, physicians’ offices or specialty clinics, and at home. The majority of services tend to be in the acute care setting. Radiation oncology, medical oncology, and chronic care clinics are excellent sites for PC involvement. Pediatric sites also include chronic care clinics, PICU and NICU, and pediatric oncology. Reimbursement for services is from direct care billing of the physician, the NP who bills at 85 percent of the physician level, and at times, an LCSW or psychologist. Other services are not considered billable and must be covered by the reimbursement of the billable providers (for example, chaplain, RN, program manager or coordinator, and social worker). The second mechanism for reimbursement is from the cost avoidance and increased bed capacity of the acute care facility. Some hospitals have paid for a percentage of PC services out of the documented cost avoidance and increased bed capacity, especially in ICU beds for facilities that have diversion issues related to ICU bed capacity. Core Staffing ‐ Disciplines and staffing models for the ideal PC Service is an interdisciplinary model of care that has dedicated staff, including: Hospice and Palliative Care Boarded Physician Hospice and Palliative Care Certified NP Nurse for care coordination Counselor‐ LCSW or PsychologistProductivity metrics are difficult to find for a PC team. This program uses the following ratio for each physician and NP full‐time equivalent (FTE): 250 consultations and 1,000 revisits/year. Competencies ‐ Competencies are not specific to the site of care, but must include the following: Care coordination Advanced care planning Palliative sedation Pain management, including opioid infusions Ethics consultation Relationship with Home Health and Hospice Teams ‐ The relationship with home health and/or hospice to all PC programs should be very strong ‐‐ either as a referral source or as a program within the home health/hospice program. The PC service is set up as a physician specialty practice. They refer patients to home health or hospice as appropriate. The hospice program purchases medical director services from the PC Medical Practice. This provides a strong tie between the hospice program and the PC program. Triggers/Tiers for Services ‐ During the early stages of development of PC, triggers can be helpful to identify potential patient referrals into the PC program. Examples are patients with: multiple hospitalizations in the last 60 days metastatic disease pain as a primary diagnosis CHF with previous hospitalizations COPD with previous hospitalizations hospital stays greater than 5‐7 days
B. Case Example: Sutter Health’s Advanced Illness Management
Sutter Health’s Advanced Illness Management (AIM®) program bridges the gaps between the hospital setting, the community physician’s office, and the home for persons living with advanced, chronic illness. These patients are considered to be at risk of dying in the next 12‐18 months and may be actively pursuing curative treatment. AIM care consists of evidence‐based, patient‐centered behaviors, actions, and protocols to ensure patients receive the right care and support at the right time, in the right place. The AIM care model relies on frequent and ongoing contact with the patient and family and thehealth for patients, and lower total cost of care. Over the past three years, the AIM program has moved from pilot operations to expanding across Sutter Health’s footprint. In 2012, the Centers for Medicare & Medicaid Innovation awarded Sutter Health a three‐year, $13 million Health Care Innovation Award to support the expansion and evaluation of the program. Supplemented by $21.4 million in Sutter Health funding, a course was set for roll out of the program in July 2012 with this mind: Improve access to PC and care management for persons with advanced illness residing within Sutter’s footprint Support CMS’ evaluation of the model in an effort to demonstrate the program’s value as a potential national care model for persons with advancing illness Use this opportunity to ‘test’ how a single, clinically integrated program might be launched to serve patients across the entire system AIM now operates in all five Sutter Health regions, with 12 teams covering 17 counties. Since the beginning of the expansion project, AIM teams have cared for more than 7,300 patients system‐wide. Nearly 500 clinicians have been trained in the AIM model of care.
Program Overview
Sutter Health’s Advanced Illness Management (AIM)® program bridges the gaps between the hospital setting, the community physician’s office, and the home for persons living with advanced, chronic illness.AIM Patients
AIM patients are considered to be at risk of dying in the next 18 months and may be actively pursuing curative treatment. To meet clinical eligibility, a patient must have a high burden of disease and one of the following: Hospice appropriate or Rapid, significant functional decline or Rapid, significant nutritional decline or Reoccurring, unplanned hospitalizations or ED visits or Physician wouldn’t be surprised if the patient died in the next 12 monthsand at the right time. Dual therapeutic approach: curative + palliative Frequent and predictable MD communication Health literate self‐management tools and communication AIM Five Pillars of Care: 1. Personal goal setting with advance care planning 2. Red flag symptom identification and management plans 3. Medication management 4. Ongoing coordination regarding physician follow up visits 5. Patient engagement and self‐management support tools Standardized note in the electronic health record (EHR), viewable across the care continuum
Core Staffing and Tiers of Service
RN and MSW services supported by Hospice and Palliative Care Certified Physician In the Hospital: AIM Care Liaison (RN) In the Home: AIM Home Health AIM Home Health RN: Visits in the home to case manage patients who meet HH eligibility; caseload 16‐18 patients AIM Home Health MSW: Visits in the home for patients who meet HH eligibility Home Health PT, ST or OT: If needed, visits in the home for patients who meet HH eligibility AIM Transitions AIM Transitions RN: Visits in the home to case manage patients who do not meet HH eligibility AIM Transitions MSW: Visits in the home for patients who do not meet HH eligibility Over the Phone: AIM Telesupport AIM Telesupport RN: Visits over the phone to case manage patients who are relatively stable, following visits from AIM Home Health or AIM Transitions AIM Triage RN: Provides after‐hours advice to patients and caregivers when contacted; provides tuck‐in services at the request of patient’s case manager Staffing Caseloads AIM HH RN average caseloads: 16‐18 with an average of 4 visits per dayAIM Intake RN AIM RN Care Coordinator& AIM MSW 12-18 months AIM Home Health AIM Transitions Physician Office
AIM RN Care Coordinator & AIM MSW
If
Acute exacerbation Pain crisis Family Anxiety
AIM RN Care Coordinator or
Office Based Case Manager
AIM Telesupport
A
Other End of Life Care
≤6 months
Home Health or Hospice
Intake or Case Manager
Competencies
Care management and coordination Medication reconciliation Symptom management Health coaching for self‐management PC consultation Advance care planningRelationship to Home Health and Hospice
AIM is a nurse‐led interdisciplinary program with MD oversight. AIM Home Health services and some AIM Transitions services are provided under the Home Health license. The remaining AIM Transitions, Telesupport and Triage services are licensed through the hospice license for PC consultative services.Reimbursement for AIM Services
AIM Home Health services are reimbursed through standard home health benefits. Other aspects of the program are funded by Sutter Health and a grant from Centers for Medicare and Medicaid Innovations. Sutter is advocating for adoption of future value‐based population reimbursement.Common Policies
AIM Administrative Eligibility Discharge from AIMBenefits of Practice Model
Dual therapeutic approach: curative + palliative High patient, caregiver and provider satisfaction The project described is supported by Cooperative Agreement Number CMS‐1C1‐12‐0001 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. These findings may or may not be consistent with or confirmed by the independent evaluation contractor.
